I had helped him understand that he had lost sight of his personal boundaries. It is natural, I had told him, that one should respond adversely to an attack on one’s central core—after all, in that situation one’s very survival is at stake. But I had pointed out that Carlos had stretched his personal boundaries to encompass his work and, consequently, he responded to a mild criticism of any aspect of his work as though it were a mortal attack on his central being, a threat to his very survival.
I had urged Carlos to differentiate between his core self and other, peripheral attributes or activities. Then he had to “disidentify” with the non-core parts: they might represent what he liked, or did, or valued—but they were not him, not his central being.
Carlos had been intrigued by this construct. Not only did it explain his defensiveness at work, but he could extend this “disidentification” model to pertain to his body. In other words, even though his body was imperiled, he himself, his vital essence, was intact.
This interpretation allayed much of his anxiety, and his work presentation last week had been wonderfully lucid and nondefensive. Never had he done a better job. Throughout his presentation, a small mantra wheel in his mind had hummed, “I am not my work.” When he finished and sat down next to his boss, the mantra continued, “I am not my work. Not my talk. Not my clothes. None of these things.” He crossed his legs and noted his scuffed and battered shoes: “And I’m not my shoes either.” He began to wiggle his toes and his feet hoping to attract his boss’s attention so as to proclaim to him, “I am not my shoes!”
Carlos’s two insights—the first of many to come—were a gift to me and to my students. These two insights, each generated by a different form of therapy, illustrated, in quintessential form, the difference between what one can derive from group therapy, with its focus on communion between, and individual therapy, with its focus on communion within. I still use many of his graphic insights to illustrate my teaching.
In the few months of life remaining to him, Carlos chose to continue to give. He organized a cancer self-help group (not without some humorous crack about this being the “last stop” pickup joint) and also was the group leader for some interpersonal skills groups at one of his churches. Sarah, by now one of his greatest boosters, was invited as a guest speaker to one of his groups and attested to his responsible and competent leadership.
But, most of all, he gave to his children, who noted the change in him and elected to live with him while enrolling for a semester at a nearby college. He was a marvelously generous and supportive father. I have always felt that the way one faces death is greatly determined by the model one’s parents set. The last gift a parent can give to children is to teach them, through example, how to face death with equanimity—and Carlos gave an extraordinary lesson in grace. His death was not one of the dark, muffled, conspiratorial passings. Until the very end of his life, he and his children were honest with one another about his illness and giggled together at the way he snorted, crossed his eyes, and puckered his lips when he referred to his “lymphoooooooooooomma.”
But he gave no greater gift than the one he offered me shortly before he died, and it was a gift that answers for all time the question of whether it is rational or appropriate to strive for “ambitious” therapy in those who are terminally ill. When I visited him in the hospital he was so weak he could barely move, but he raised his head, squeezed my hand, and whispered, “Thank you. Thank you for saving my life.”
3
“The Wrong One Died”
A few years ago, while preparing a research proposal on bereavement, I placed a brief article in a local newspaper which ended with this message:In the first, planning stage of his research, Dr. Yalom wishes to interview individuals who have been unable to overcome their grief. Volunteers who are willing to be interviewed, please call 555-6352.
Of the thirty-five people who phoned for an appointment, Penny was the first. She told my secretary that she was thirty-eight years old and divorced, that she had lost her daughter four years previously, and that it was urgent for her to be seen immediately. Although she worked sixty hours a week as a taxicab driver, she emphasized that she would come in for an interview at any hour of the day or night.
Twenty-four hours later she was sitting opposite me. A rugged, brawny woman: weathered, battered, proud—and trembling. You could tell she had been through a lot. She reminded me of Marjorie Main, the tough-talking movie star of the 1930s, now long dead.
The fact that Penny was in crisis, or said she was, presented me with a dilemma. I could not possibly treat her; I had no hours available to take on a new patient. Every minute of my time was committed to completing a research proposal, and the deadline for the grant application was rapidly approaching. That was the top priority in my life then; that was why I had advertised for volunteers. Furthermore, since I was leaving on sabbatical in three months, there was insufficient time for a decent course of psychotherapy.
To prevent any misunderstanding, I decided it would be best to clarify at once the issue of therapy—before I got in too deep with Penny, before I even asked why, four years after her daughter’s death, she needed to be seen immediately.
So I started by thanking her for volunteering to speak to me for two hours about her bereavement. I informed her that it was important for her to know, before she agreed to proceed, that these were to be research, not therapeutic, interviews. I even added that, though there was a chance that talking might help, it was also possible that talking might be temporarily unsettling. If, however, I thought therapy were needed, I would be glad to help her select a therapist.
I paused and looked at Penny. I was entirely satisfied with my words: I had covered myself and had been clear enough to prevent any misunderstandings.
Penny nodded. She rose from her chair. For an instant I was alarmed because I thought she would walk out. But she simply smoothed out her long denim skirt, sat back down, and asked if she could smoke. When I handed her an ashtray, she lit up and, in a strong deep voice, began: “I need to talk, all right, but I can’t afford therapy. I’m strapped. I’ve seen two cheap therapists—one was still a student—at the county clinic. But they were afraid of me. No one wants to talk about a child’s dying. When I was eighteen, I went to a counselor at an alcohol clinic who was an ex-alcoholic—she was good, she asked the right questions. Maybe I need a shrink who’s lost a kid! Maybe I need a real expert. I have a lot of respect for Stanford University. That’s why I jumped when I saw the newspaper story. I always thought my daughter would go to Stanford—if she had lived.”
She looked straight at me and spoke right out. I like hard women, and I liked her style. I noticed that I began to speak a little tougher.
“I’ll help you talk. And I can ask hard questions. But I ain’t going to be around to pick up the pieces.”
“I heard you. You just help get me started. I’ll take care of me. I was a latchkey kid when I was ten.”
“O.K., begin with why you wanted to see me immediately. My secretary said you sounded desperate. What’s happened?”
“A few days ago, I was driving home from work—I finish up about one in the morning—and I had a blackout. I woke up and I was driving on the wrong side of the road and screaming like a wounded animal! If there had been any traffic coming the other way, I wouldn’t be here today.”
That was how we began. I was unnerved by the image of this woman screaming like a wounded animal, and took a few moments to clear it from my mind. Then I started asking questions. Penny’s daughter, Chrissie, had developed a rare form of leukemia when she was nine and died four years later, one day before her thirteenth birthday. During those four years Chrissie attempted to stay in school but was bedridden almost half the time and hospitalized every three or four months.
Her cancer and her treatment were both extremely painful. During her four years of illness, many courses of chemotherapy had prolonged her life but left her, each time, bald and agonizingly ill. Chrissie had
had dozens of painful bone marrow extractions and so many bloodlettings that finally there were no more veins to be found. During the last year of her life, her physicians had installed a permanent intravenous catheter that permitted easy access to her bloodstream.
Her death, Penny said, was awful—I couldn’t imagine how awful. At this point she started to sob. True to my word to ask hard questions, I urged her to tell me about how awful Chrissie’s death had been.
Penny had wanted me to get her started; and, by sheer chance, my first question unleashed a torrent of feeling. (Later I was to learn that I would reach deep pain in Penny no matter where I probed.) Chrissie had died, finally, of pneumonia: her heart and lungs had failed; she couldn’t breathe and, in the end, drowned in her own fluids.
The worst thing, Penny told me between sobs, was that she couldn’t remember her daughter’s death: she had blacked out Chrissie’s final hours. All she remembered was going to sleep that evening alongside her daughter—during Chrissie’s hospitalizations Penny slept on a cot next to her—and, much later, sitting at the head of Chrissie’s bed with her arms around her dead daughter.
Penny began to talk about guilt. She was obsessed with the way she had behaved during Chrissie’s death. She could not forgive herself. Her voice became louder, her tone more self-accusatory. She sounded like a prosecuting attorney trying to convince me of her dereliction.
“Can you believe,” she said, “I can’t even remember when, I can’t remember how I learned my Chrissie had died?”
She was certain, and soon convinced me she was correct, that the guilt about her shameful behavior was the reason she couldn’t let Chrissie go, the reason her grief had been frozen for four years.
I was determined to pursue my research plans: to learn as much as possible about chronic bereavement and to design a structured interview protocol. Nonetheless, possibly because there was so much therapy to be done, I found myself forgetting the research and, little by little, slipping into a therapeutic mode. Since guilt seemed to be the primary problem, I set about, for the rest of the two-hour interview, learning as much as possible about Penny’s guilt.
“Guilty of what?” I asked. “What are the charges?”
The main charge she brought against herself was that she had not been really present with Chrissie. She had, as she put it, played a lot of fantasy games. She had never allowed herself to believe that Chrissie would die. Even though the doctor had told her that Chrissie was living on borrowed time, that no one had ever recovered from this disease, even though he said, point-blank, when she last entered the hospital, that she could not live much longer, Penny refused to believe that Chrissie would not get well again. She was full of fury when the doctor referred to the final pneumonia as a blessing that should not be interfered with.
In fact, she had not accepted that Chrissie was dead even now, four years later. Just a week previously, she “woke up” to find herself in a drugstore checkout line with a gift for Chrissie in hand, a stuffed animal. And at one point in my interview with her, she said that Chrissie “will be” seventeen next month, instead of “would be.”
“Is that such a crime?” I asked. “Is it a crime to keep on hoping? What mother wants to believe her child has to die?”
Penny replied that she hadn’t acted out of love for Chrissie but instead had put herself first. How? She had never helped Chrissie talk about her fears and her feelings. How could Chrissie talk about dying to a mother who continued to pretend it wasn’t happening? Consequently, Chrissie was forced to be alone with her thoughts. What difference did it make if she slept next to her daughter? She really wasn’t there for her. The worst thing that can happen to someone is to die alone, and that was the way she had let her daughter die.
Then Penny told me that she had a deep belief in reincarnation, a belief that began when she was a teenager and miserable and poor and so tormented by the thought that she had been gypped in life that she could find consolation only in the thought that she would have another chance. Penny knew that next time around she would be luckier—perhaps richer. She knew also that Chrissie was going on to another, healthier, happier life.
Yet she hadn’t helped Chrissie die. In fact, Penny was convinced that it was her fault Chrissie’s dying took so long. For her mother’s sake, Chrissie had stayed around, prolonging her pain, delaying her release. Though Penny didn’t remember the final hours of Chrissie’s life, she was certain that she did not say what she should have said: “Go! Go! It’s time for you to go. You do not have to stay here for me any longer.”
One of my sons was then in his teens, and, as she spoke, I began to think of him. Could I have done it, let go of his hand, helped him die, told him, “Go! It is time to go”? His sunny face hovered in the eye of my mind and a wave of inexpressible anguish enveloped me.
“No!” I told myself, shaking myself free. Getting inundated with emotion was likely what happened to the others, to the therapists who couldn’t help her. I saw that, to work with Penny, I would need to lash myself to the mast of reason.
“So what I hear you say is that you feel guilty about two main things. First, because you didn’t help Chrissie talk about dying, and second, because you didn’t let go of her soon enough.”
Penny nodded, sobered by my analytic tone, and her sobbing stopped.
Nothing offers more false security in psychotherapy than a crisp summary, especially a summary containing a list. My own words heartened me: the problem seemed suddenly clearer, more familiar, far more manageable. Though I had never before worked with anyone who had lost a child, I ought to be able to help her since much of her grief was reducible to guilt. Guilt and I were old acquaintances, both personal and professional.
Earlier Penny had told me that she was in frequent communion with Chrissie, visiting her daily in the cemetery and spending an hour a day grooming her grave and talking to her. Penny devoted so much energy and attention to Chrissie that her marriage deteriorated, and her husband left for good about two years before. Penny said she hardly noticed his going.
As a memorial to Chrissie, Penny had kept her room unchanged, with all her clothes and possessions in their familiar places. Even her last, unfinished homework assignment lay on the desk. Only one thing had been changed: Penny took Chrissie’s bed into her own room and slept on it every night. Later, after I had interviewed more bereaved parents, I would learn how commonplace such behavior was. But then, in my naiveté, I thought it outrageous, unnatural, something that had to be put right.
“So you deal with your guilt now by hanging on to Chrissie, by not getting on with your life?”
“I just can’t forget her. You can’t throw a switch on and off, you know!”
“Letting go of her is not the same thing as forgetting—and nobody is asking you to throw a switch.” I was now convinced it was important to answer Penny right back: when I stayed tough, she got more resilient.
“Forgetting Chrissie is like saying I never loved her. It’s like saying that your love for your own daughter was just something temporary—something that fades. I won’t forget her.”
“‘Won’t’ forget her. Well that’s different from being asked to throw a switch.” She had ignored my distinction between forgetting and letting go, but I let it pass. “Before you can let go of Chrissie, you need to want to, to be willing to. Let’s try to understand this together. For the moment, pretend you’re hanging on to Chrissie because you choose to. What does this do for you?”
“I don’t know what you’re talking about.”
“Yes, you do! Just humor me. What do you get out of hanging on to Chrissie?”
“I deserted her when she was dying, when she needed me. No way I’m going to desert her again.”
Though Penny didn’t yet understand, she was locked into an irreconcilable contradiction between her determination to stay with Chrissie and her reincarnation beliefs. Penny’s grief was stuck, gridlocked. Perhaps, if she confronted this contradiction, she could start grieving a
gain.
“Penny, you talk to Chrissie every day. Where is Chrissie? Where does she exist?”
Penny’s eyes widened. No one had ever before asked such blunt questions. “On the day she died, I brought her spirit back home again. I could feel it in the car with me. At first she stayed around me, sometimes at home in her room. Then later I could always make contact in the cemetery. She usually knew what was going on in my life, but she’d want to know about her friends and her brothers. I stayed in touch with all her friends so I could tell her about them.” Penny paused.
“And now?”
“Now she’s fading. Which is good. It means she’s been reborn into another life.”
“Does she have any memory of this life?”
“No. She’s into another life. I don’t believe in this shit about remembering past lives.”
“So she’s got to be free to go on to her next life, and yet there’s a part of you that won’t let her go.”
Penny said nothing. She just stared at me.
“Penny, you’re a tough judge. You put yourself on trial for the crime of not letting Chrissie go when she was about to die, and you sentenced yourself to self-hatred. I personally think you judge yourself too harshly. Show me the parent who could have done otherwise. I’ll tell you, if my child were dying I couldn’t have. But, even worse, the sentence is so severe—so damn tough on yourself. It sounds like your guilt and grief have already broken up your marriage. And the length of the sentence! That’s what really blows my mind. It’s four years now. How much longer? Another year? Four more? Ten? A life sentence?”
I collected my thoughts, trying to decide how to help her see what she was doing to herself. She sat motionless, a cigarette smoldering in the ashtray in her lap; her gray eyes were fixed on me. She hardly seemed to breathe.